Provider Demographics
NPI:1104362979
Name:LISA M. PETRICA-MOSER, PH.D. INC.
Entity Type:Organization
Organization Name:LISA M. PETRICA-MOSER, PH.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARI
Authorized Official - Last Name:MOSER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:727-244-5975
Mailing Address - Street 1:1790 CAPTIVA DR
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-5220
Mailing Address - Country:US
Mailing Address - Phone:727-244-5975
Mailing Address - Fax:
Practice Address - Street 1:2727 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6383
Practice Address - Country:US
Practice Address - Phone:727-244-5975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5976261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health